Provider Demographics
NPI:1427588953
Name:PETTY, ALEX JOSEPH (BS)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JOSEPH
Last Name:PETTY
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36703 E COUNTY ROAD 1590
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-9604
Mailing Address - Country:US
Mailing Address - Phone:405-207-6621
Mailing Address - Fax:
Practice Address - Street 1:202 S WASHITA AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-7820
Practice Address - Country:US
Practice Address - Phone:405-665-4385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty